WebM&M Cases & Commentaries
WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by our readers. Spotlight Cases include interactive learning modules available for CME. Commentaries are written by patient safety experts and published monthly. Contribute by Submitting a Case anonymously.
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- Communication Improvement 13
- Culture of Safety 2
- Education and Training 8
- Human Factors Engineering 6
- Logistical Approaches 2
- Quality Improvement Strategies 10
- Specialization of Care 1
- Teamwork 2
- Clinical Information Systems 2
- Device-related Complications 2
- Diagnostic Errors 11
- Discontinuities, Gaps, and Hand-Off Problems 9
- Identification Errors 1
- Medical Complications 1
- Medication Safety 3
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 3
- Surgical Complications 2
- Spotlight Case
Elliott K. Main, MD; November 2016
After an emergency cesarean delivery, a woman had progressive tachycardia and persistent hypertension. A CT scan showed no evidence of pulmonary embolism, but repeat blood tests showed a dangerously low hemoglobin level and markedly elevated liver enzyme levels. She was taken back to the operating room and found to have postpartum hemorrhage.
Jennifer Malana, MSN, RN, and Audrey Lyndon, PhD, RN; October 2016
A pregnant woman was admitted for induction of labor for postterm dates. Prior to artificial rupture of membranes (AROM), the intern found a negative culture for group B strep in the hospital record but failed to note a positive culture in faxed records from an outside clinic. Another physician caught the error, ordered antibiotics, and delayed AROM to allow time for the medication to infuse.
- Spotlight Case
Charlie C. Kilpatrick, MD; September 2015
After several days of abdominal pain, nausea, and vomiting, a pregnant woman visited the emergency department and was swiftly discharged with antibiotics for a UTI. However, she returned the next day with unchanged abdominal pain and more nausea and vomiting. Apart from a focused ultrasound to document her pregnancy, no further testing was done. The patient again returned the following day with increased pain and now appeared more ill. An MRI revealed a ruptured appendix.
- Spotlight Case
Mark W. Scerbo, PhD, and Alfred Z. Abuhamad, MD; January 2015
A woman who had an uncomplicated pregnancy and normal labor with no apparent signs of distress delivered a cyanotic, flaccid infant requiring extensive resuscitation. Although fetal heart rate tracings had shown signs of moderate-to-severe fetal distress for 90 minutes prior to delivery, clinicians did not notice the abnormalities on the remote centralized monitor, which displayed 16 windows, each for a different patient.
Vanitha Janakiraman Mohta, MD; February 2012
A pregnant woman with new onset hypertension and proteinuria was admitted to the hospital for further testing. Test results for a 24-hour urine collection were initially reported as normal in the electronic medical record, and discharge planning was begun. However, a later amended report showed the results were elevated and abnormal, confirming a diagnosis of preeclampsia.
Baha Sibai, MD; June 2010
A woman with chronic hypertension developed undiagnosed preeclampsia during pregnancy with twins. At 38 weeks, she experienced respiratory and cardiac arrest. Although she eventually recovered, the infants were stillborn.
- Spotlight Case
Gail B. Slap, MD, MSc; February 2010
An overweight teenaged girl came to the pediatrics clinic for routine follow-up of her type 2 diabetes, complaining of nonspecific, intermittent abdominal pain and worsening acne. The physician prescribed topical acne cream and increased her diabetes medications. The next day, an obstetrician notified the pediatrician that this patient had delivered a healthy infant via Caesarian section overnight.
Shareen El-Ibiary, PharmD, BCPS; November 2008
A pregnant woman with asthma was admitted to the hospital with respiratory distress. Although the emergency department providers noted that she was pregnant, this information was not conveyed to the floor. On admission, the patient was given an antibiotic that could have been dangerous.
Mitch Rodriguez, MD, MBA; Rebecca Mannel, BS, IBCLC; Donna Frye, RN, MN; September 2008
After several pediatric visits, parents of a newborn with low output and weight loss contact a lactation consultant, who discovered that ankyloglossia (tongue-tie) was preventing the infant from receiving adequate intake from breastfeeding.
Philip Darney, MD, MSc; April 2006
A woman has an intrauterine contraceptive device placed at the time of "her period." A month later it is discovered that she is pregnant, as she had been at the time of the insertion.
Louis P. Halamek, MD ; December 2005
A resident in the middle of delivering an infant turns away for a moment, during which the mother adjusts herself and the infant drops headfirst onto the floor.
Mark D. Pearlman, MD; Jeffrey S. Desmond, MD; May 2005
A woman who was 38 weeks pregnant came to the emergency department (ED) complaining of left leg pain. Ruled out for deep vein thrombosis, she was sent home, only to die the following morning.
Neil A. Holtzman, MD, MPH; December 2004
A pregnant woman is offered genetic testing for herself and her husband. Although he declines, the next time he undergoes routine testing, the phlebotomist overrides the consent in the computerized record and runs the test anyway.
Ann Williamson, PhD, RN; May 2004
An antenatal room left in disarray causes a charge nurse to search for the missing patient. Investigation reveals that a resident had performed an ultrasound on a nurse friend rather than a true "patient."
Marcelle I. Cedars, MD; January 2004
A pregnant woman arrives at the ED with severe abdominal pain. Concerned about a ruptured appendix, the ED physicians order a CT scan. The obstetrics resident examines her there and is concerned about a ruptured heterotopic pregnancy.
Mark A. Rosen, MD; November 2003
Due to the delay in anesthesiology becoming available for an urgent C-section, an infant is delivered with profound neurologic abnormalities.
Lee A. Learman, MD, PhD; June 2003
A woman was told she miscarried, even though she was still pregnant.
Vanessa M. Givens, MD; Gary H. Lipscomb, MD; May 2003
A woman is given methotrexate prematurely for suspected ectopic pregnancy and ultimately has salpingectomy.
Jackie Thomas, MD; Mary Hannah, MD; April 2003
Incorrect dating criteria in a woman late entering prenatal care nearly leads to induction of a pre-term infant.
Verna C. Gibbs, MD; Lucian L. Leape, MD ; February 2003
A woman required emergency vascular surgery due to a complication during routine laparoscopic tubal ligation.